Department of Labor and Employment Division of Workers' Compensation 633 17th St., Suite 400, Denver, CO 80202-3626 Telephone: 303.318.8640 Fax: 303.318.8739 EXCLUSION OF UNCOMPENSATED PUBLIC OFFICIALS Name of Agency: __________________________________________________________________________________ Federal Employer Identification # (FEIN): __________________________Business Phone #: (______)______________ Mailing Address: __________________________________________________________________________________ Street or P.O. Box / Suite # ________________________________________________________________________________________________ City State Zip If Self-Insured Employer, enter the Permit Number: _______________________________________________________ If not Self-Insured, enter the workers' compensation insurance carrier name and policy number: ________________________________________________________________________________________________ Insurance Carrier Name Policy Number Upcoming Policy Period: From: _________________ Month / Year To: ________________________ Month / Year List the Governing Body for the Agency, Category of uncompensated officials (i.e. board, commission, etc.) or any combination of categories of such officials that you are opting to exclude from coverage for the upcoming policy year and Names of Officials (Attach additional pages if needed): Name of Governing Body: __________________________________________________________________________ Category _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ Name of Official _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ C.R.S. section 8-40-202(1)(a)(I)(B) provides an option to exclude from workers' compensation insurance coverage uncompensated elected or appointed officials. You must promptly notify each official of your exercise of the option to exclude them. This form must be filed with the Division of Workers' Compensation not less than forty-five (45) days before the start of the policy period for which the option is to be exercised. Attach governing body's resolution. By signing this form, you are certifying that the above-named uncompensated, elected or appointed public officials are designated to be excluded from worker's compensation coverage for the upcoming policy year, pursuant to C.R.S. section 8-40-202(1)(a)(I)(B). You are also certifying that these officials have been notified of this exclusion. Signature: ______________________________________________________________________________________ Print Name: _____________________________________________________________________________________ Date: __________________ Title: ___________________________________________________________________ Submit this form with the Governing Body's Resolution to: Division of Workers' Compensation, Coverage Enforcement Unit, 633 17th St., Suite 400, Denver, CO 80202-3626. If insured, please make a copy of this completed form and send it to your insurance carrier. If you have any questions, contact the Division of Workers' Compensation Customer Service Unit at 303.318.8700. C.R.S. section 10-1-128(6)(a) states: " It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies." WC44 Rev 02/12 American LegalNet, Inc. www.FormsWorkFlow.com